Title Dural Arteriovenous Malformation of the Tentorium
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Dural Arteriovenous Malformation of the Tentorium : Report Title of a Case and a Review of the Literature
Author(s) HANDA, JYOJI; SHIINO, AKIHIKO; KIDOOKA, MINORU
Citation 日本外科宝函 (1988), 57(1): 107-114
Issue Date 1988-01-01
URL http://hdl.handle.net/2433/203923
Right
Type Departmental Bulletin Paper
Textversion publisher
Kyoto University Arch Arch Jpn Chir 57(1), 107 ～ 114, Jan., 1988
Dural Dural Arteriovenous Malformation of the Tentorium. Report Report of a Case and a Review of the Literature
Jvo;r Jvo;r RANDA, AKIHIKO Sttrrno, and MINoRu KmooKA From the Department of Neurosurgery, Shiga University of Medical Science, Seta, Seta, Ohtsu, 520-21 Shigaken, Japan (Diector: (Diector: Prof. Dr. ]YOJI RANDA)
Summary/ Abstract
A case of a 58-year-old man with the dural arteriovenous malformation (A VM) confined to
the the cerebellar tentorium and presented with repeat 巴d intracranial hemorrhages is reported. A
review review of the literatur 巴 revealed 14 similar cases of dural A VM con 五ned to the t巴ntorium. A
drainage drainage via the leptom 巴ningeal veins with or without varix and a high incidence of intracranial hemorrhage were common to 15 cases including ours.
Dural arteriov 巴nous malformation (A VM) accounts for approximately 10% of all intra-
cranial cranial A VMs. They most often involve the dura mater of th 巴 posterior fossa surrounding the sigmoid sigmoid and transverse sinuses (7), or the dura mater of the middle fossa in the region of the cavernous cavernous sinus (8, 16). Dural AVMs restricted to the cerebellar tentorium seem to be extremely extremely rare, and a careful review of the literature has found previous reports of only 14 cases (1, (1, 4, 5, 6, 11, 12, 13, 14, 15), to which we wish to add one.
Report of a Case
This This 58-year-old man had b 巴en healthy until May 11, 1986, when he noticed acute sever 巴 occipital occipital headaches and nausea, which spontaneously subsided in a few days. Severe headaches
recurred recurred on May 18. A spinal tap at that time yielded th 巴 bloody cerebrospinal 丑uid, and cerebral cerebral angiography found an AVM. After two weeks' conservative treatment, the patient was discharged without neurologic deficits.
On Septemb 巴r 7, 1986, how 巴ver, S巴vere headaches recurred, associated with repeated vomit- ing, ing, speech disturbance and gait disturbance. He was readmitted to a hospital, and computed tomography (CT) scan found a cerebellar hematoma and triventricular hydrocephalus. A ventricular ventricular drainage was performed, and he was transferred to us on September 22, for further examination examination and treatment. On admission, the patient was alert but his neck was stiff. Neurologic examination showed Key Key words: AVM, Dural AVM, Intracranial hemorrhage, Varix. 索引語：動静脈奇形，硬膜動静脈奇形，頭蓋内出血，静脈癒． Reprint Reprint requests to: Jyoji Handa, M.D., Department of Neurosurgery, Shiga University of Medical Science,
Seta, Seta, Ohtsu, 520 21 Shiga 司 ken, Japan. 108 108 日外宝第57 巻第1 号（昭和63 年 1 月）
Fig. Fig. 1. (A) plain and (B) enhanced CT obtained on September 30. Low density area in the the cerebellum in A corresponds to an aged hematoma and/or edema. In B, an abnormal abnormal enhancement is seen in the tentorium along the left petrous ridge (arrowheads) (arrowheads) and in the left cerebellopontine angle region. (CJ Repeat CT on October October 2, showing fresh cerebellar hemorrhage. paresis paresis of the left Vth, Vlth, VIIth, IXth and Xth cranial nerves, and limb ataxia on the left side. side. Repeat CT scan showed a low density focus in and around the left cerebellar peduncle. After an intravenous administration of the contrast medium, abnormal enhancement was seen in the left cerebellopontine angle region as well as in the tentorium along the left petrous ridge (Figure lA, B).
Fig. Fig. 2. Frontal projection of selective left internal carotid angiogram, (AJ early and (BJ late late arterial phase. An A VM fed by the tentorial branch and drained via a vaicose vaicose vein is opacified. DURAL A VM OF TENTORIUM 109
Fig. Fig. 3. Lateral projection of selective left internal carotid angiogram, (A) early and (B) late late arterial phase. An A VM involving the tentorium, enlarged tentorial branch as as a main feeding artery, and a varicose dilatation of the draining vein are shown.
Cerebral Cerebral angiography found an A VM involving the left anteromedial part of the cereb 巴Har tentorium. tentorium. Main feeding arteries were tentorial branch of the left internal carotid arte 巧r and occipital occipital and middle meningeal art 巴ries of the left external carotid origin. The A VM was drained drained via a varicose dilatation to the petrosal and internal cerebral veins (Figures 2, 3 & 4).
Selectiv 巴 injection of the contrast medium into the vertebral M 吋 showed a faint opacification
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／’ d「
Fig. Fig. 4. (AJ Frontal and (BJ lateral projection of selective left external carotid angiogram. The middle meningeal artery and the occipital artery participated in the blood supply supply to the AVM. 110 110 日外宝第57 巻第1 号（昭和63 年 1 月）
Fig. Fig. 5. Lateral projection of (A) arterial and (B) late arterial phase of vertebral angiogram, angiogram, showing the varix faintly.
of of the varicose dilatation, but the feeding arteries and the further draining routes could not be identified identified (Figure 5). The ventricular drain was removed, but the condition of the pati e nt remained stable until October 2, when he acutely lapsed into coma. An emergency CT scan found a large cerebellar hematoma (Figure lC), and marked triventricular hydrocephalus. The patient underwent a ventricular drainage. He recovered consciousness within a few hours, but neurological examination examination showed marked worsening of limb ataxia on the left side and dysarthria . Left Left temporal craniotomy was performed on October 14. Gentle retraction of the temporal lobe lobe revealed a dural AVM involving the anteromedial portion of the tentorium near its free edge. edge. The tentorium was incised along the superior petrosal sinus. A large dural artery, apparently apparently representing an enlarged tentorial branch of the internal carotid artery, was encoun- tered tered near the free edge. It was clipped and divided. Inspection of the cerebellopontine angle region region through a hole made by tentorial incision found a large red vein leaving the dural AVM from the lower surface of the tentorium and entering the varicose vein. A triangular piece of the the tentorium was resected, including the nidus of the AVM. At this point, the red vein and varix varix discolored and collapsed. They were coagulated and divided. A total removal of the AVM was confirmed later by repeated postoperative angiography. Four months later, the patient patient was transferred to an institution for the purpose of further rehabilitation.
Discussion
The dural A VM most often involves the dura mater of or near the cavernous sinus, or the DURAL AVM OF TENTORIUM 111
dura dura mater in the region of the lateral and sigmoid sinuses . The former occurs most often in elderly elderly woman, and it may cause chemosis, conjunctiva! hyperemia, proptosis, ophthalmoplegia,
retro-orbital retro-orbital pain, and occasionally diminish 巴d visual acuity. However, the s戸nptoms are generally generally fewer and milder than those seen in direct carotid-cavernous sinus fistulas, and spon- taneous taneous closure or closure following diagnostic angiography has been reported. The dural A VM of the transverse-sigmoid sinus, on the other hand, usually presents cranial bruits, bruits, tinnitus, headache, and seizures, and a subarachnoid hemorrhage occurs in 10 to 20% of cases cases (17). Dural A VMs in this region often accompany obstruction of one or both sigmoid sinuses . They are usually thought to be congenital , but recently it has been described that at least least some of them are acquired lesions, developing after a head injury (3). Complete eradication of of such lesions either by operation or by endovascular procedures is often extremely di 伍cult. Dural A VMs in the region of the anterior cranial fossa are infrequent, but they are unique
in in that [1] they are most often supplied by th 巴 ethmoidal branches of the ophthalmic artery, [2] they they are drained into the dural venous sinuses not directly but the via cortical veins which are often often dilated, and [3] they present usually with intracranial hemorrhage (9, 10). Dural AVMs confined to the cerebellar tentorium such as seen in this patient seem to be very very rare . After a careful review of the literature , we could collect reports of only 14 previous cases cases (1, 4, 5, 6, 11 14, , 13, 12, 15) . Pertinent clinical data of a total of 15 patients including the the present case are summarized in the table. Ten patients were the male and five were the female, ranging in age from 33 to 72 years , with with a mean of 54. Clinically, patients with this group of dural A VMs showed a rather homo- geneous geneous presentation that is quite similar to that with dural A VMs in the base of the anterior fossa fossa but differs significantly from lesions draining directly into th e lateral and sigmoid sinuses. Fourteen Fourteen out 15 of patients presented with intracranial hemorrhage. In 9 patients hemorrhage involved involved mainly the subarachnoid space whereas in 5 patients intr ac erebral hematoma developed. Multiple Multiple feeding arteries were identified in all patients except one (4). The tentorial arteηF or or the meningohypophyseal trunk fed th で A VM in 10 patients , the middle meningeal arte 可 in 8 patients , and the occipital arteηr and the posterior meningeal branch in 6 patients each. The ascending ascending pharyngeal artery, the stylomastoid artery, the accessory meningeal artery and the tentorial tentorial branch of the posterior cerebral artery were also found to have the fed tentorial A VM in in a small number of cases. Reviewing the records of 15 cases in detail, however, it seems to be especially especially noted that the mode of drainage was directly into the dural venous sinuses in only 1 case (4) , and through the cortical veins (type 3 drainage route of the classification by Castaigne (2)) (2)) in all other 14 patients . In 7 of those 14 patients , in addition , the draining cortical vein showed a varicose dilatation as often seen in lesions in the anterior cranial fossa . Presence of such such long course of leptomeningeal draining veins with or without varicose dilatation before ending ending finally in the dural venous sinuses is highly characteristi c in, and con 立non to, dural AVMs of th 巴 anterior cranial fossa as well as tentorial dural A VMs, and it is considered to be the the cause of a high incidence of intracranial hemorrhage in both . Also in the present patients, the the operation found that the sour ce of h 巴morrhage was the varicose draining vein in the 57 巻第1 号（昭和63 年 1 月） 112 112 日外宝第 Table 1. Dural A VM confined to the tentorium.
YEAR AGE/ PRESEN- FEEDERS DRAINER VARIX TREATMENT RESULT 出 AUTHOR SEX TATION Feeder Feeder 1963 1963 33 /M SAH MMA, TA, via cortical + 1 Laine PMA ve in ligation None 1972 1972 47 /F 。 TA direct to 2 Debrun cavernous sinus sinus Excision Excision 1973 1973 62 /F 。 TA , MMA vi a cortical + 3 Aminoff vem // // // 4 // 。 51 /M 。 TA,MMA, OA,PMA Multiole Multiole 5 Kosnik 1974 52/M // TA, OA // op.,_ op.,_ ~nally exc1s1on exc1s1on NmCodH PTO MBAAJE 51 /M ’ // Excision 6 Miyasaka 1980 uIed U 側 A bhbωdbhudnhlfOE ’ // ＋ 池田 ’内伎 Negative 7 Fardoun 1981 54 /M 伎町 follow - up p ang1ogram 一 日比国同 nr 8 Grisoli 1984 36 /M SAH TA,MMA // ＃ －m No deficit 9 // // 64 /M !CH TA,OA, η ph AsphA q Good 10 10 // 。 55 /F SAH MMA,TA, // PMA ＋＋ FddFHe白川白山rfr＆ GRMnuaLLopeded 11 11 // 11 68 /F ICH AccMA, 町 r剖ロ AsphA, － StmA Aea eob ast SAH OA, PMA, // 12 12 Malik 1984 72/M 旧 団山 PAurA 13 13 // // 48 /F !CH TA,PMA, // ＋ Embol., MMA,OA, lat er CavlCA exc1s10n 14 14 Lasjaunias 1986 52 /M SAH MMA, TA, // AsphA 15 15 Handa 1988 58 /M SAH/ TA, OA, 町 十 Excision Negative ICH MMA follow-up angiogram angiogram
Abbrevi ation: M: mal e, F: female, SAH: subarachnoid hemorrhage, ICH: intracerebral hemorrhage, MMA: middle meningeal artery, TA : tentorial artery, or meningohypophyseal trunk, PMA : posterior meningeal meningeal artery, OA: occipital artery, TB-PCA: tentoiral branch of posterior cerebral artery, AsphA: ascending ascending pharyng eal artery, AccMA: accessory meningeal artery, PAurA: posterior auricular artery, CavICA: cavernous internal carotid artery, op .: op erations, embol: embolization.
cerebellopontine cerebellopontine angle . With dural AVMs in general, distal ligation of the feeding arteries seems most often to result result in failure because it does not reduce the blood flow to the nidus su 伍ciently enough to produce a total obstruction. Recently, embolization or occlusion with a detachable balloon of feeders feeders has been proposed by many authors. With tentorial dural AVMs, however, the tentorial artery artery or the meningohypophyseal trunk most often is the principal feeding artery. It is not necessarily necessarily easy to occlude it by such methods, and the risk of an inadvertent occlusion of the cerebral cerebral artery can not be excluded. In sharp contrast to the dural A VMs of the transverse- DURAL AVM OF TENTORIUM 113 sigmoid sinuses, however, the direct surgical approach to the nidus with interruption of all the afferent afferent vessels and a direct r巴moval of the nidus together with a piece of the tentorium is a relatively easy task with dural A VMs confin 巴d to th 巴 cerebellar tentorium, and this would appear to the treatment of choice with this rare but potentially highly dangerous condition.
References
1) 1) Aminoff MJ: Vascular anomalies in the intracranial dura mater. Brain 96: 601-612, 1973. 2) 2) Castaigne P, Laplane D, Djindjian R, et al: Communication arterioveineuse spontanee entre la carotide externe externe et le sinus caverneux. Rev Neurol (Paris) 114: 5-14, 1966. 3) 3) Chaudhaary MY, Sachdev VP, Cho SH, et al: Dural arteriovenous malformation of the major venous sinuses: sinuses: An acquired lesion. AJNR 3: 13-19, 1982. 4) 4) Debrun G, Chartres A: Infra and supratentorial arteriovenous malformations. A general review. About 2 cases of spontaneous supratentorial arteriovenous malformation of the dura. Neuroradiology 3: 184-192, 1972. 1972. 5) 5) Fardoun R, Adam Y, Mercier P, et al: Tentorial arteriovenous malformation presenting as an intracerebral hematoma. Case report. J Neurosurg 55: 976 978, 1981. 6) 6) Grisoli F, Vincentelli F, Fuchs S, et al: Surgical treatment of tentorial arteriovenous malformations draining into into the subarachnoid space. Report of four cases. JN eurosurg 60: 1059 1066, 1984. 7) 7) Halbach VV, Higashida RT ‘Hieshima GB, et al: Dural fistulas involving the transverse and sigmoid sinus 田： Results of treatment in 28 patients. Radiology 163: 443-447, 1987. 8) 8) Halbach VV, Higashida RT, Hieshima GB, et al: Dural fistulas involving the cavernous sinus: Results of treatment treatment in 30 patients. Radiology 163: 437-442, 1987. 9) 9) Handa J, Shimizu Y: Dural arteriovenous anomaly supplied by anterior falcine artery. Neuroradiology 6: 6: 212 214, 1973. 10) 10) Kidooka M, Nakasu S, Nakasu Y, et al: Dural arteriovenous malformation in the anterior cranial fossa: Report Report of a case. Arch Jpn Chir 51: 1040-1046, 1982. 11) 11) Kosnik EJ, Hunt WE, Miller CA: Dural arteriovenous malformations. J Neurosurg 40: 322 329, 1974. 12) 12) Lasjaunias P, Chiu M, TerBrugge K, et al: Neurological manifestations of intracranial dural arteriovenous malformations. malformations. J N eurosurg 64: 724 ー730, 1986. 13) 13) Line E, Galibert P, Lopez C, et al: Anevrysmes arterio-veineux intra-duraux (developpes dans lepaisseur de la la dure-mere) de la fosse posterieure. N eurochirurgie 9: 147 158, 1963. 14) 14) Malik GM, Pearce JE, Ausman JI, et al: Dural arterio-venous malformations and intracranial hemorrhage. Neurosurgery Neurosurgery 15: 332 339, 1984. 15) 15) Miyasaka K, Takei H, Nomura M, et al: Computerized tomography 五ndings in dural arterio-venous malformations. malformations. Report of three cases. J Neurosurg 53: 698-702, 1980. 16) 16) Newton TH, Hoyt WF: Dural arteriovenous shunts in the region of the cavernous sinus. Neuroradiology 1・71-81, 1970. 17) 17) Obrador S, Soto M, Silvela J: Clinical syndromes of artriovenous malformations of the transverse-sigmoid sinus. sinus. JN eurol N eurosurg Psychiatry 38: 436-451, 1975. 114 114 日外宝第57 巻第1 号（昭和63 年 1 月）
和文抄録
小脳天幕 l乙限局した硬膜動静脈奇形
滋賀医科大学脳神経外科 半田譲二，椎野顕彦，木戸岡実
58 才男で頭蓋内出血を繰りかえした小脳天幕の硬膜 面を走行し，しかもしばしば静脈癌様拡大を伴ない， 動静脈奇形の例を報告した．乙の部の硬膜動静脈奇形 乙れが頭蓋内出血を多発する原因と思われる．検・ S はまれで， 14 例の報告をみるにすぎない．しかし，計 状静脈洞lζ 注ぐ通常の後頭蓋禽硬膜動静脈奇形と異な 15 例中14 例は頭蓋内出血を呈し，又，血管撮影上，流 り，天幕の 1 部を含めた全刻出が最善の処置である． 出静脈は硬膜静脈洞に注ぐ前に長い距離に亘って脳表